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- Review and abstract inpatient chart documentation to include history and physicals, progress notes, consultations, operative reports and discharge summaries
- Ensure compliance with regulatory and third-party insurance requirements in utilizing the International Code of Diseases-10 Clinical Modifications (ICD-10-CM), and Procedure Coding System (PCS) coding books
- Identify the appropriate Evaluation and Management based on the type of professional services rendered.
- Adhere to coding practices prescribed by the Department of Defense (DoD), Defense Health Agency (DHA), The Joint Commission (TJC), American health Association (AHA) Coding Clinic and Center for Medicare and Medicaid Services (CMS) coding guidelines.
- Enter codes using MHS Genesis software, the 3M Clinical Coding Editor (CCE) or applicable systems.
- Maintain daily productivity reports including completed activity, all metrics and incomplete activities.
- Confirm that the correct patient data is contained in the medical record to ensure that incorrect demographics are not entered into a file. Name, social security number or DoD ID number and dates of services are verified.
- Perform utilization review of records to assure diagnosis responsible for the length of stay is appropriately identified and the secondary diagnoses are sequenced properly to assure maximum allocation under the Diagnosis Related Group (DRG) system.
Medical Records Administration Specialist - Naval Medical Center, San Diego, United States - Department Of Defense
Description
Summary
About the Position: This position is location in the Directorate of Administration, Medical Records Coders at Naval Medical Center, San Diego, California.
This is a Direct Hire Solicitation
Inpatient Coding position.
One of the following certifications, is highly preferred: American Health Information Management Associate (AHIMA), Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or American Academy of Professional Coders (AAPC) Certified Professional Coder.